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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> N*scqnsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)fqr4he system,on p4per not less than 8-1/2 x 11 inches in size. <br /> CountSta43 rtary.�t Number Checkif revision to prev us application State Plan I D.Number <br /> ccrn� - <br /> I.Application Information-Please Print all Information Location: n ) <br /> Property Owner Name t q / // Property Location / Jw <br /> S4�ve- r''�4 l'� 1 4111 tyt i n S611411i W1/4,s2-7T ,N,Rt "' W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> So k1A r+Ie Woo8 Irl o e <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> fix.? 7-6L4 v.- 1•j4vx5 3 r ( 9 S2- ) �73`7 7TMY l E& b i✓q <br /> II.Tylie of Building: (check one) ❑city C'v u 6L <br /> CK 1 or 2 Family Dwelling-No.of Bedrooms: 3 12Village <br /> ❑Public/Commercial(describe use):_ ¢S,To�wn of/ <br /> ❑State-Owned t,vDCld el Ue'r <br /> NeVest Road ` <br /> lar, 1w <br /> Parcel Tax Number(s)6 Z. 07g- <br /> 111. <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. Q9 Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ®Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks L — <br /> 7-�r t x /000) k-ivr 19L ❑ ❑ ❑ ❑ <br /> Ili ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Nameroer <br /> ) umber's Sign re stamps): MP/MPRS No. Business Phone Number <br /> e S r � V- 22 S Z Z c. C �� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date issued Issui nt Signatu stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) fy ��ed <br /> Determination l lJ <br /> X. onditions of Approval/Reasons for Disapproval: <br /> ------------ <br /> SBD-6398(R.07/00) <br />